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New-Onset Atrial Fibrillation after cesarean delivery; The unusual cardiac event in the postpartum setting
Abstract Number: FC10-172
Abstract Type: Case Report Case Series
Case: A 38 y/o at 37.2 weeks of pregnancy presented with elevated blood pressure. She had previous C-sections but denied any medical problem. Cesarean delivery was indicated for preeclampsia with uncontrolled hypertension. She was treated with 5 mg of IV hydralazine and 4 g of Mg Sulfate before surgery. CSE anesthesia was induced without any difficulty. Immediately after delivery, she started complaining of chest discomfort and occasional PVCs were observed with sinus tachycardia. After she was given 2 mg of IV midazolam, tachycardia was resolved. In PACU, she developed tachycardia with irregular heartbeat up to 150/min on a cardiac monitor. On 12 lead EKG, new onset of atrial fibrillation (AF) with rapid ventricular response was revealed. Metoprolol 5 mg IV was given initially, and then IV Esmolol infusion was started to control the rate on continuous cardiac monitoring. Her initial evaluation including electrolytes, urine drug screen, thyroid studies, an echocardiogram, and CT chest was all normal. She continued showing atrial fibrillation 12 hours postoperatively. Concerning persistent AF, the decision was made to start anticoagulation for possible electrical cardioversion. While preparing electrical cardioversion, her arrhythmia was converted to sinus rhythm spontaneously. She was discharged home on metoprolol 12.5 mg without anticoagulation.
Discussion: During pregnancy, there are many physiologic changes which place pregnant women at the risk of developing cardiac arrhythmia. AF without preexisting heart disease during pregnancy is a very rare occasion. In addition to physiologic changes, our patient had comorbidities with preeclampsia. This patient developed AF with a rapid ventricular response after spinal anesthesia with additional vasodilators. According to the recent article, it showed the high rate of spontaneous cardioversion up to 81% of AF episodes with a structurally normal heart in pregnancy (1). The treatment of choice is the rate control with beta blockers. If AF is persistent, cardioversion can be considered with anticoagulation. The protection against thromboembolic complications by continuing anticoagulation can be determined based on the assessment of thromboembolic risk in the postpartum setting.
Reference: 1. Cumyn A, Sauvé N, Rey É. Atrial fibrillation with a structurally normal heart in pregnancy: An international survey on current practice. Obstet Med.2017; 10(2):74–8.